DHA Case No. CWA 216813 (Wis. Div. Hearings and Appeals May 9, 2025) (DHS) ↓ Download PDF The IRIS waiver requires IRIS Consultant Agencies (ICAs) to monitor participants’ health and safety, address health and safety concerns with the participant, and ultimately disenroll participants when health and safety concerns remain despite remediation efforts. In this case, […] Read more

DHA Case No. CWA 217415 (Wis. Div. Hearings and Appeals May 5, 2025) (DHS) ↓ Download PDF The Department may disenroll IRIS participants if it cannot develop a plan that ensures the participant’s health and safety. In this case, the petitioner’s behavior support plan—staff call 911 and seek refuge in their cars if he gets […] Read more

DHA Case No. FCP 215537 (Wis. Div. Hearings and Appeals Jan. 24, 2025) (DHS) ↓ Download PDF Family Care services must generally be from appropriate and qualified providers, be fair and safe, serve to maintain community connections, and be cost effective. In this sympathetic case, the petitioner—a competent 43-year-old man with muscular dystrophy, severe respiratory […] Read more

DHA Case No. CWA 215921 (Wis. Div. Hearings and Appeals Jan. 22, 2025) (DHS) ↓ Download PDF Providers are generally not allowed to restrain MA participants, but this rule can be waived after an application to the Department. In this case, the petitioner had a waiver that expired June 21, 2024. Although his mother reapplied […] Read more

DHA Case No. FCP 217629 (Wis. Div. Hearings and Appeals May 5, 2025) (DHS) ↓ Download PDF When a Family Care member has a significant change in circumstances, the MCO must reassess the member’s care needs. In this case, the petitioner had multiple emergency room visits and was ultimately hospitalized, resulting in a reassessment and […] Read more

DHA Case No. CWA 216742 (Wis. Div. Hearings and Appeals Aug. 4, 2025) (DHS) ↓ Download PDF Under the Wisconsin Equal Access to Justice Act (WEAJA), petitioners who prevail in a fair hearing are entitled to an award of costs unless the agency’s action was “substantially justified.” In this case, the petitioner successfully appealed the […] Read more

DHA Case No. FCP 216187 (Wis. Div. Hearings and Appeals Apr. 25, 2025) (DHS) ↓ Download PDF In the Family Care program, the MCO may not deny a service that is reasonable and necessary to support the member’s long-term care outcomes—but it must also be cost-effective, and it can exclude a service the client wants […] Read more

DHA Case No. CWA 216742 (Wis. Div. Hearings and Appeals May 14, 2025) (DHS) ↓ Download PDF One service IRIS can provide is Daily Living Skills (DLS), which teaches and improves skills to improve the participant’s independence in daily life. Because it is educational, the service is monitored to ensure progress is being made. In […] Read more

DHA Case No. CWA 215300 (Wis. Div. Hearings and Appeals Dec. 17, 2024) (DHS) ↓ Download PDF IRIS participants are assigned a budget, and their IRIS Consultant Agency (ICA) cannot authorize services exceeding that budget. In this case, the petitioner overbilled her supportive home care budget for many months. Her ICA reduced her authorized supportive […] Read more

DHA Case No. CWK 215379 (Wis. Div. Hearings and Appeals Dec. 12, 2024) (DHS) ↓ Download PDF Under the approved Waiver, DHS does not allow for the use of personal restraints and strictly limits the use of protective equipment. In this case, the petitioner was an 8-year-old autistic child who needed a diaper but exhibited […] Read more

DHA Case No. MPA 215583 (Wis. Div. Hearings and Appeals Dec. 9, 2024) (DHS) ↓ Download PDF Medicaid covers prescriptions drugs that are medically necessary, guided by agency policy on the effective, appropriate, and cost-effective use of the drug. For anti-obesity drugs, specifically Wegovy, agency policy limits coverage to 12 continuous months, after which the […] Read more

DHA Case No. CWA 213491 (Wis. Div. Hearings and Appeals Oct. 24, 2024) (DHS) ↓ Download PDF Home modifications for an IRIS participant must be cost-effective. In this case, the petitioner asked that his tub/shower be replaced with a walk-in shower. The accessibility study concluded this was needed and explained why less expensive options would […] Read more

DHA Case No. CWK 211705 (Wis. Div. Hearings and Appeals Sep. 10, 2024) (DHS) ↓ Download PDF Individual choice of provider is a main tenet of the CLTS program. Even when a county has concerns about a provider, the County Waiver Agency must respect the participant’s choice “unless there is compelling justification not to do […] Read more

DHA Case No. FCP 216075 (Wis. Div. Hearings and Appeals Feb. 24, 2025) (DHS) ↓ Download PDF When an MCO seeks to reduce services, it has the burden of proof and must justify its action. In this case, an Inclusa representative justified its reduction of Supportive Home Care (SHC) hours from 496 to 446 per […] Read more